Psoriasis

Question 1

What is psorisis?

Answer 1

Chronic, non-infectious, auto-inflammatory skin disease with exacerbations and remissions

Question 2

Psoriasis is characterized by?

Answer 2

well-demarcated erythematous plaques topped by silvery scale on certain predilection areas
Note; has a high psycosocial burden

Question 3

Epidemiology?

Answer 3

1. Prevalence 1-4% of the population worldwide
   – US 3.7%
   – Africans, African Americans and Asians: 0.4-0.7%
   – East Africa: data not sufficient
2. Men= Women
3. Psoriasis can occur in children but is less common as atopic dermatitis

Question 4

Psoriasis triggers?

Answer 4

1. Infection
   e.g. streptococcus, HIV
2. Drugs
   e.g. β-blockers, lithium, antimalarials, ACE inhibitors, nonsteroidal anti-inflammatory drugs
3. Stress
4. Trauma

Question 4

Pathophysiology key findings?

Answer 4

1. Abnormal epidermal proliferation and differentiation: from 23 d to 3-5 d
2. Inflammation
3. Increased angiogenesis

Question 5

Pathophysiology of psoriasis caused by triggers?

Answer 5

1. Trigger leads to activation of T cells, dendritic cells and macrophages
2. These activated cells release interleukins and chemokins
3. This leads to a proliferation of the keratinocytes

Question 6

Histopathology of psoriais?

Answer 6

1. Parakeratosis (persistence of nuclei in stratum corneum)
2. Acanthosis
3. Inflammation
4. Increased angiogenesis

Question 7

Different variants of psoriasis?

Answer 7

1. Classic plaque psoriasis
2. Scalp psoriasis
3. Flexural or inverse psoriasis
4. Nail psoriasis
5. Palmoplantar psoriasis
6. Pustular palmoplantar psoriasis
7. Guttate psoriasis
8. Erythrodermic psoriasis
9. Psoriatic arthritis

Question 8

General findings of psoriasis?

Answer 8

1. Sharply demarcated erythemato-squamous plaques, with silvery white scales
2. Usually asymptomatic, although some patients have mild pruritis
3. Limited - generalized

Question 9

Typical general phenomena of psorisis?

Answer 9

1. Candle-wax or silvery scales
2. Koebner phenomenon
3. Auspitz sign

Question 10

Predilection sites psoriasis?

Answer 10

1. Scalp 80%
2. Elbows 78%
3. Legs 74%
4. Knees 57%
5. Arms 54%
6. Trunk 53%
7. Sacral 38%
8. Palms and soles 12%

Question 11

Describe chronic plaque psoriasis?

Answer 11

• Diagnosed in 80-90% patients
• Symmetrical distributed, sharply defined erythematous squamous plaques
• Coin to palm sized plaques usually present months to years
• Nails in 10 to 55%

Question 12

Describe scalp psoriasis?

Answer 12

• Most commonly involved
• Especially hairline and temporal regions
• Spread 1-2 cm into adjacent skin
• Usually no hair loss

Question 13

Describe flexural/inverse psoriasis?

Answer 13

Psoriasis in intertriginous areas
1. Sharply demarcated shiny, red/pink plaque
2. Different appearance
– No scaling
– Plaques are thinner
– Often pruritic
3. Often centrally fissure
4. Fungal/bacterial infections are a common trigger

Question 14

Describe nail psoriasis?

Answer 14

• 30-80%
• Finger nails more common than toe nails
• Pain + restriction in daily activities
• Most patients with psoriatic arthritis have nail involvement

Question 15

Describe features of nail psoriasis?

Answer 15

1. Pits
2. Distal onycholysis
3. Oil spots
4. Subungual hyperkeratosis
5. Splinter hemorrhages

Question 16

Describe palmoplantar psoriasis?

Answer 16

1. symmetric, sharply demarcated, erythematous plaques
2. Adherent scaling

Question 17

Describe pustular palmoplantar psoriasis?

Answer 17

• Individual or coalescing sterile pustules 1mm to 1 cm: Begin yellow then turn brown
• Mainly in women
• Smoking ++
• Rare in children
• 70%: hands and feet, 20% only feet, 10% only hands

Question 18

How to tell if it is erytrodermic psoriaisis?

Answer 18

1. Previously classic plaques
2. Facial sparing
3. Nail changes
4. More adherent scaling

Question 18

Describe guttate psoriasis?

Answer 18

• “Droplet” lesions mainly trunk
• Usually children and young adults
• Sudden onset
• Spares palms and soles
• Often preceded by infection: streptococcal
• In children good prognosis, in adults tend to be chronic

Question 18

Describe erytrodermic psoriasis?

Answer 18

Difficult to distinguish from other causes of erythroderma

Question 19

Pathophysiology of psoriatic arthritis?

Answer 19

1. Inflammation and TNF-a cause abnormal fast epidermal turnover
   > Plaques on the surface
2. TNF-a causes inflammation of synovial membranes and lead to
   bone erosions, hyperostoses and deformation

Question 19

Describe psoriatic arthritis?

Answer 19

• 20 % of cutanous psoriasis pts have psoriatic arthritis
• Seronegative (rheumafactor negative) spondyloarthritis
• Mainly hands, feet, knees, wrists and ankles
• Erosive changes (X-ray)

Question 20

Describe the relationship between psoriasis and HIV?

Answer 20

• Development of eruptive psoriasis or sudden exacerbation of a pre existent psoriasis can be due to HIV infection
• Severity increases with degree of immunodeficiency
• Less responsive to treatment
• Often negative family history

Question 21

Predeliction of sites of psoriasis in HIV?

Answer 21

1. Face, often seborrhoic distribution 2. Flexures 3. Palmoplantar surfaces – Nails 4. More often erythroderma

Question 22

Ddx for chronic plaque psoriasis?

Answer 22

1. Discoid eczema 2. Tinea corporis 3. Bowen’s disease 4. Subacute lupus erythematosis 5. Mycosis fungoides

Question 23

Ddx for Guttate psoriasis?

Answer 23

1. Secondary syphilis 2. Tinea corporis 3. Pityriasis rosea

Question 25

Ddx for erytroderma?

Answer 25

1. Atopic dermatitis 2. Pityriasis rubra pilaris 3. Drug reactions 4. Sezary syndrome

Question 25

Ddx for pustular palmoplantar psoriasis?

Answer 25

1. Eczema 2. Fungal Infection

Question 25

Explain the high social burden of psoriasis?

Answer 25

1. Difficulty finding a job 2. Job complications e.g time off work, discrimination 3. Financial distress 4. Embarrassment when show psoriasis in public 5. Sexual activity concerns

Question 25

Management of psoriasis?

Answer 25

1. patient education 2. lifestyle modification 3. medical treatment

Question 26

Comorbidities associated with Psoriasis?

Answer 26

1. Cardiovascular disease 2. Metabolic syndrome 3. Obesity 4. Depression 5. Increased risk for infection (most clearly in patients with erythrodermic psoriasis) 6. Malignancies 7. Psoriatic arthritis 8. Other immune-mediated inflammatory diseases (Crohn’s disease)

Question 27

Explain patient eductaion?

Answer 27

1. Chronic skin disorder which waxes and wanes 2. Disease course can be very unpredictable 3. Treatment is to get control of the disease and not to cure it 4. Complete clearance may not be achievable 5. Get rid of myths that its contagious or a sign of cancer 6. Explain how to apply topical therapies

Question 28

Lifestyle modification?

Answer 28

1. Healthy diet (As less sugar as possible, lots of fresh vegetables) 2. No smoking/alcohol 3. Sleeping 4. Exercise 5. Stress management: mindfulness/meditation

Question 29

Medical treatment?

Answer 29

1. topical 2. phototherapy 3. systemic

Question 30

Topical treatment?

Answer 30

1. Corticosteroids 2. Vitamin D3 analogue (Calcitriol) 3. Tar 4. Dithranol

Question 31

Phototherapy treatment?

Answer 31

1. Sunlight 2. UVB 3. PUVA

Question 32

Systemic treatment?

Answer 32

1. MTX 2. Ciclosporin 3. Fumarates 4. Retinoids (acitretin) 5. Apremilast 6. Biologicals

Question 33

Treatment for mild psoriasis?

Answer 33

Only topical treatment 1. First remove scaling – Salicylic acid 10% – Application of emollients 2. Potent corticosteroids (+/- vit. D. derivate)/Tar/Dithranol - Potent corticosteroid under occlusion (2x/wk, leave on for 2-3 days)

Question 34

Moderate/severe psoriasis treatment?

Answer 34

1. Continue local therapy with emollient/salicylic acid 2. Treatment with UVB/PUVA therapy or exposure to sunlight: 2-3 times a week, 3 months

Question 35

Severe psoriasis treatment?

Answer 35

1. systemic therapy 2. fumarates 3. biological

Question 36

What is the systemic therapy in treating severe psoriasis?

Answer 36

1. Methotrexate - more suitable for long term treatment, but hepatotoxic 2. Ciclosporin - rapid response, but risk of hypertension and nephrotoxicity 3. Acitretin - oral retinoid - mono therapy mainly effective in pustular and erytrodermic psoriasis, combination with PUVA is effective in chronic plaque psoriasis

Question 37

Methotrexate dose?

Answer 37

10-25 mg ONCE a week

Question 38

Investigations to be done when administering methotrexate?

Answer 38

Lab-Tests: 1. Cellular Blood count+ diff. at baseline, - after 1 & 2 weeks, then 2-monthly, (Bone marrow !) 2. Renal FT, Liver FT.

Question 39

Contraindications of methotrexate?

Answer 39

1. Family planning (female) 2. Pregnancy/Breast feeding 3. Severe infections 4. Severe reduced Liver and renal function 5. Alcohol abuse 6. Hematologic disease 7. Restricted lung capacity 8. Severe heart insufficiency